The Role of Community Health Workers in Promoting Health: 'Talk to Me About Anything'

Feb 28, 2014, 9:00 AM

Shreya Kangovi, MD, is an assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine, executive director of the Penn Center for Community Health Workers, and a Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholars program alumna.

“What do youthink will help you stay healthy after discharge?”

Mr. Manzi, a soft-spoken man in his early 60s, paused to consider. No one had asked him this question before. He had come to the hospital because of blurry vision and thirst too severe to ignore. The doctors told him that he had severe diabetes and hypertension, and that he needed to adhere to a long list of new medications, tests, and appointments.

“Not just medical stuff,” Anthony, the community health worker, continued. “Talk to me about anything. Dealing with shut-off notices, housing issues, whatever you think you need to stay healthy.”

Mr. Manzi opened up. He explained that he was originally from Ghana but had been living and working odd jobs in Philadelphia for 20 years as an undocumented immigrant. He had not had a job in six months and twice, his home had gone into foreclosure. Mr. Manzi was uninsured and had not been able to get outpatient care before coming to the hospital.

“I’m willing to do whatever it takes to stay healthy,” he concluded. “But I need to make sure I can pay for all of these medications and a doctor. And I need some help with the foreclosure—I can’t take care of myself if I lose my home.”

Mr. Manzi’s answers became the basis for his tailored intervention. IMPaCT (Individualized Management for Patient-Centered Targets) is an innovative model of care in which community health workers (CHWs) provide tailored support to help patients achieve individualized goals. Anthony, an IMPaCT CHW, shares socioeconomic background with patients like Mr. Manzi. He and other IMPaCT CHWs are selected for traits such as empathy, active listening, and reliability.

Over the next two weeks, Anthony helped Mr. Manzi to reach the goals he had identified. Anthony asked the inpatient team to prescribe Mr. Manzi medications that were on a $4 formulary. Together, Anthony and Mr. Manzi called a local African cultural center that provided financial planning, and obtained a three-month mortgage modification. Anthony accompanied Mr. Manzi to his first appointment at a community health center recommended by Anthony’s other African patients because of its low co-pays and immigration advocacy services.

Mr. Manzi achieved his goals and was on a path to better health.

While Mr. Manzi’s story is illustrative, skeptical audiences should demand more rigorous evidence of effectiveness. Last year, I led a study that tested a two-week dose of IMPaCT in a randomized controlled trial of 446 socioeconomically vulnerable inpatients. Results of the study, published in JAMA Internal Medicine, show that the intervention group was more likely to obtain timely post-hospital primary care (60.0 percent vs 47.9 percent); to report high-quality discharge communication (91.3 percent vs 78.7 percent); and to show greater improvements in mental health (6.7 percent vs 4.5 percent) and patient activation (3.4 percent vs 1.6 percent). While the groups had similar rates of at least one hospital readmission (15 percent vs 13.6 percent), the IMPaCT group was less likely to have multiple readmissions (2 percent vs 6 percent).

The Affordable Care Act (ACA) makes health care organizations across the country accountable for outcomes such as those measured in this trial. Organizations are investing substantial resources into a variety of innovative delivery models (e.g. post-discharge phone calls, nurse navigators, automated hovering, etc.) Yet, they rarely require the same level of evidence for these investments as they would for a new medical device or a pharmaceutical. In order to avoid waste or adverse outcomes, the exciting health care delivery changes that have been spurred by the ACA should be evidence-based.

Unlike devices or pharmaceuticals, evidence-based health care delivery innovations are often difficult to scale, or translate from research to practice. This is because innovations are often not standardized and are described only in a brief scientific manuscript. The Penn Center for Community Health Workers was created to ensure that evidence-based CHW models, such as IMPaCT, are integrated into routine health care delivery. This Center has created an open-source toolkit (including staff hiring guidelines, a college-accredited CHW training course, and detailed manuals for daily work practice and supervision) to help other organizations adapt and implement the IMPaCT model.

Providers work so hard to diagnose the cause of patients’ health problems and to prescribe a course for remedy. Yet, it turns out that patients themselves may know the root causes of—and solutions to—their health problems. Patients’ solutions are often not the expensive, high-tech medical interventions that we might have prescribed. Rather, patients may benefit from the support of a trusted CHW. “I was ashamed and afraid to talk about my immigration and foreclosure problems. But Tony understood ... he’s knows where I’m coming from.”